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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 11362 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t 1. Job Address1 ff- F � 0 � 64wk—f City (To Size _ PM -77 Owner's Narrve S fZ� ESS4W Address ( SJ �• Y Phone s1_ Contractor's Name I ucen>;e No• O Phone TYPE OF WELL_/PUMP: NEIN WELL ❑ WELL RE CEMENT ❑ DESTRUCTION :-_J PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SE&IC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE _— FOUNDATION a AGRICULTURE WELL !_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ---Industrial-.-_ —.._❑_Open Bottom__ ❑..Manteca-_-__-Dia--of..Well Excavation. ! ______Dia. of Well Casing. -- -.-.-- -- XQomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications O Public ❑ Other 11 Delta Depth of Grout Seal _ Type of Grout __ . ❑ Irrigation _-4pprox. Depth 10 Eastern Surface Seal Installed by Repair Work Done C Type of Pump H. 77)'�-- State Work Done ZIi3S7444 1AJ UJF Well Destruction G Well Diameter _ Sealing Material (top 50'1 — Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑f; REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial` Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet _ __Water table depth SEPTIC TANK ❑ Type/Mfg __ Capacity_ No. Compartments PKG. TREATMENT PLT. LJ �, Method of Disposal Distance to nearest: 'Well Foundation Property Line LEACHING LINE No. & Length of lines _ Total length/sue _ — FILTER BED F' Distance to nearest: Well Foundation Property Line C�" SEEPAGE PITS El Depth Size _ Number '' f SUMPS "❑ Distance to nearest: Well Foundation Property Line ?. ' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and- ruies and regulations of,the San Joaquin Local Health District. Home owner or erased agent's,signetuie certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe in such manner as-to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the fol wi g:"I certlfy�thaviri the rfomlance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of if ia."� "' i- The applican call for al r d in s_ Cam to drawing on reverse side. )•�_� Signed Title: L +�"�' -- Date: F DEPARTMENT USE ONLY , Application Accepted by _ Date (�� -) Area Pk or Grout Inspection by t Date incl Inspection by 1 Additional Comments: ❑ Stk 466-6781 C; Lodi 389-3621 ❑ Manteca 823-7104 C Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT"N0. I INFO / 111 « EH 1324 IREV.101M �/a , 5-9-�s 9.5--YK/� I EH 14-20 f